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ARRAR
..TRAUS
IROUX
34 THE NEW YORKER, DECEMBER 14, 2009
DEPI OF MEDICINE
TESTING, TESTING
The health-care bill has no master plan jòr curbing costs. Is that a bad thing?
BY ATUL GAWANDE
C ost is the spectre haunting health re-
form. For many decades, the great
flaw in the American health-care system
was its unconscionable gaps in coverage.
Those gaps have widened to become
graves-resulting in an estimated forty-
five thousand premature deaths each
year-and have forced more than a mil-
lion people into bankruptcy. The emerg-
ing health-reform package has a master
plan for this problem. By establishing in-
surance exchanges, mandates, and tax
credits, it would guarantee that at least
ninety-four per cent of Americans had
decent medical coverage. This is historic,
and it is necessary. But the legislation has
no master plan for dealing with the prob-
lem of soaring medical costs. And this is a
source of deep unease.
Health-care costs are strangling our
country. Medical care now absorbs eigh-
teen per cent of every dollar we earn. Be-
tween 1999 and 2009, the average an-
nual premium for employer-sponsored
family insurance coverage rose from
$5,800 to $13,400, and the average cost
per Medicare beneficiary went from
$5,500 to $11,900. The costs of our dys-
functional health-care system have al-
ready helped sink our auto industry, are
draining state and federal coffers, and
could ultimately imperil our ability to
sustain universal coverage.
What have we gained by paying more
than twice as much for medical care as
we did a decade ago? The health-care
sector certainly employs more people
and more machines than it did. But
there have been no great strides in ser-
vice. In Western Europe, most primary-
care practices now use electronic health
records and offer after-hours care; in the
United States, most don't. Improvement
in demonstrated medical outcomes has
been modest in most fields. The reason
the system is a money drain is not that
it's so successful but that it's fragmented,
disorganized, and inconsistent; it's ne-
glectful of low-profit services like mental-
health care, geriatrics, and primary care,
and almost giddy in its overuse of high-
cost technologies such as radiology im-
aging, brand-name drugs, and many
elective procedures.
At the current rate of increase, the cost
of family insurance will reach twenty-
seven thousand dollars or more in a de-
cade, taking more than a fifth of every dol-
lar that people earn. Businesses will see
their health-coverage expenses rise from
ten per cent of total labor costs to seven-
teen per cent. Health-care spending will
essentially devour all our future wage in-
creases and economic growth. State bud-
get costs for health care will more than
double, and Medicare will run out of
money in just eight years. The cost prob-
lem, people have come to realize, threatens
not just our prosperity but our solvency.
So what does the reform package do
about it? Turn to page 621 of the Senate
version, the section entided "T ransform-
ing the Health Care Delivery System,"
and start reading. Does the bill end med-
icinè s destructive piecemeal payment sys-
tem? Does it replace paying for quantity
with paying for quality? Does it institute
nationwide structural changes that curb
costs and raise quality? It does not. In-
stead, what it offers is. . . pilot programs.
This has provided a soft target for crit-
ics. "Two thousand seventy-four pages
and trillions of dollars later," Mitch Mc-
Connell, the Senate Minority Leader, said
recendy, "this bill doesn't even meet the
basic goal that the American people had
in mind and what they thought this debate
was all about: to lower costs." According
to the Congressional Budget Office, the
bill makes no significant long-term cost
reductions. Even Democrats have become
nervous. For many, the hope of reform
was to re-form the health -care system. If
nothing is done, the United States is on
track to spend an unimaginable ten trillion
dollars more on health care in the next de-
cade than it currendy spends, hobbling
government, growth, and employment.